Provider Demographics
NPI:1073787834
Name:LAUREL MEDICAL SUPPLIES, INC.
Entity Type:Organization
Organization Name:LAUREL MEDICAL SUPPLIES, INC.
Other - Org Name:FREDERICK MEDICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LETIZIA
Authorized Official - Suffix:
Authorized Official - Credentials:ATP
Authorized Official - Phone:814-472-5591
Mailing Address - Street 1:179B THOMAS JOHNSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4871
Mailing Address - Country:US
Mailing Address - Phone:301-378-2266
Mailing Address - Fax:301-378-2204
Practice Address - Street 1:179B THOMAS JOHNSON DRIVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4871
Practice Address - Country:US
Practice Address - Phone:301-378-2266
Practice Address - Fax:301-378-2204
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAUREL MEDICAL SUPPLIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-14
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2549332B00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD412780300Medicaid
PA0162870002Medicare NSC